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RC261  .D85  The  interest  of  the 


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THE    INTEREST    OF    THE    COM- 
MUNITY  IN   CANCER 


Read  before  the  New  York  Academy  of  Medicine,  in  Associa- 
tion with   the  American   Society  for  the 
Control  of  Cancer,  May  18,  1916 


BY 

LOUIS  I.  DUBLIN,  Ph.D.,  Statistician 
Metropolitan  Life  Insurance  Company,  New  York 

1916 


The  Interest  of  the  Community  in 
Cancer"^ 


LOUIS     I.    DUBLIN,     Ph.D. 

Statistician,   Metropolitan  Life  Insurance  Company 
NEW    YORK 


The  interest  of  the  community  in  cancer  can  best  be 
characterized,  perhaps,  by  contrasting  this  disease  with 
another  that  is  still  more  familiar,  namely,  tuberculosis. 
The  average  age  at  death  from  tuberculosis  is  about  Z7 
years ;  from  cancer  it  is  about  twenty  years  greater. 
Tuberculosis  affects  primarily  the  economic  interest  of 
the  community.  The  decedent  is  usually  at  the  highest 
point  of  his  efficiency ;  his  productive  period  is  still 
largely  in  the  future ;  his  children  are  either  very 
young  or  still  unborn.  In  cancer,  on  the  other  hand, 
the  productive  period  is  for  the  most  part  in  the  past ; 
the  children  have  been  born,  and  the  family  unit  is  only 
slightly  disturbed  economically  by  the  death,  since  in 
the  majority  of  cases  the  offspring  have  reached  the 
age  of  self-support  and  independence.  It  is,  therefore, 
the  emotional  interest  that  is  uppermost.  The  long  suf- 
fering of  the  patient,  and  the  utter  hopelessness  of  the 
condition  in  its  advanced  stages,  appeal  tremendously 
to  the  humanitarian  feeling  of  the  community.  The 
economic  niterest  in  cancer,  although  important,  must 
remain  secondary. 

Our  interest  is  accelerated  by  the  mystery  that  still 
surrounds  the  disease.  The  prevalence  of  cancer  has 
been  noted  in  the  earliest  history  of  civilized  man. 
Today  it  is  responsible  for  one  death  out  of  every  four- 
teen among  men,  and  for  one  death  out  of  every  nine 

*  Read  before  the  New  York  Academy  of  Medicine,  in  association 
with    the   American    Society    for    the    Control    of    Cancer,    May    18,    1916. 


among  women,  after  the  age  of  50.  Yet,  in  spite  of 
the  weakh  of  chnical  material  and  the  concentration  of 
effort,  it  has  withstood  every  attempt  of  the  physician 
and  scientist  to  unravel  its  secret.  The  world  is  still 
baffled  as  to  the  cause  of  cancer.  Only  a  beginning  has 
been  made  in  its  study;  the  heart  of  the  problem  is  still 
sealed  to  us.  The  scientific  spirit  of  present-day  medi- 
cine demands  an  explanation,  and  the  community  as  a 
whole  supports  this  demand  insistently  and  whole- 
heartedly. 

Additional  interest  results  from  the  disquieting  fact 
that  the  cancer  rate  may  be  increasing.  The  chief 
sources  of  information  on  their  face  indicate  an 
increase.  This  holds  true  not  only  for  the  Registration 
Area  of  the  United  States  and  for  those  of  our  states 
whose  records  are  most  reliable,  but  also  for  the  United 
Kingdom,  for  Switzerland,  for  Germany  and,  indeed, 
generally  throughout  the  civilized  world.  I  shall  not  go 
into  the  complex  statistical  problem  involved  in  deter- 
mining whether  this  increase  is  real  or  only  apparent. 
Equally  good  authorities  have  divided  on  this  impor- 
tant question.  My  own  judgment  is  that  there  may 
very  well  be  an  increase.  I  am  struck,  however,  with 
the  number  of  possibilities  of  serious  error  in  using 
figures  which  are  usually  quoted  to  prove  an  increase, 
especially  in  our  own  country.  The  figures  are  too 
striking  to  be  true.  In  the  ten-year  period  from  1901 
to  1910,  there  was  an  increase  of  30  per  cent,  in  the 
male  cancer  rate,  and  of  22  per  cent,  in  the  female  can- 
cer rate,  at  all  ages  beginning  with  the  age  of  25,  in  the 
states  included  in  the  Registration  Area  in  1900.  At 
certain  age  periods  this  increase  was  very  considerable 
— as  much  as  40  per  cent.  The  unreliability  of  these 
figures  is  at  once  apparent  when  we  think  of  cancer  as 
a  disease  of  long  standing  in  our  civilization.  By  pro- 
jecting such  increases  in  the  rates  forward  or  back- 
ward a  few  generations,  we  are  led  at  once  to  an 
absurdity;  for  if  cancer  were  capable  of  increasing  at 
such  a  pace  it  would  either  have  been  a  negligible  dis- 
ease in  the  recent  past  or  would  seriously  threaten  the 
verv  existence  of  the  race  in  the  near  future. 


We  must  consider,  in  seeking  for  an  explanation  of 
the  increasing  rates,  first,  the  marked  improvement 
of  registration  in  general  in  our  country  during  the  last 
fifteen  years,  and  second,  the  greater  certainty  in  the 
diagnosis  of  cancer  by  physicians,  which  has  resulted 
from  the  increase  in  the  number  of  operations  and 
laboratory  examinations.  We  shall  have  to  wait  at 
least  ten  years  under  present  conditions  of  registration 
in  our  country  to  know  definitely  what  has  happened. 
There  are  already  indications  that  the  cancer  rate  has 
reached  its  highest  point,  and  that  in  certain  commun- 
ities it  is  beginning  to  decline. 

But  whether  or  not  cancer  is  on  the  increase  is  really 
secondary  to  the  much  more  important  fact  that  the 
rate  at  present  is  extremely  high.  The  condition  today 
is  a  real  menace.  In  order  that  we  may  determine  the 
extent  of  the  problem  that  is  before  us,  it  is  necessary 
to  refer  to  a  few  basic  figures.  The  accompanying 
tables  are  constructed  from  the  experience  of  the 
Industrial  Department  of  the  Metropolitan  Life  Insur- 
ance Company.  They  are  valuable  because  of  their 
intrinsic  accuracy,  a  quality  which  most  cancer  rates, 
unfortunately,  do  not  possess.  The  figures  have  also 
the  merit  of  being  based  on  a  large  exposure.  In  the 
Metropolitan  experience  there  are  represented  over 
10,000,000  persons,  both  white  and  colored — men, 
women  and  children  of  all  ages  above  1.  The  number 
of  persons  exposed  and  the  corresponding  number  of 
deaths  are  known  with  a  high  degree  of  accuracy.  The 
rates  have  furthermore  the  particular  value  of  applying 
to  the  working  classes  of  the  United  States  and 
Canada. 

The  first  column  in  Table  1  shows  the  death  rates 
from  cancer  for  all  persons,  without  distinction  of  sex 
or  color.  The  rate  at  all  ages  is  69.7  per  hundred  thou- 
sand exposed.  This  rate  is  based  on  a  total  of  23,660 
cancer  deaths  which  occurred  in  the  four  years  1911  to 
1914.  In  the  remaining  columns,  rates  for  white  and 
for  colored  persons  of  each  sex  are  given. 

Without  devoting  attention  to  the  numerous  interest- 
ing aspects  of  this  table,  I  may  nevertheless  point  out  a 


few  striking  derivations.  First,  the  cancer  rate  is  much 
higher  among  females  than  among  males.  Second,  the 
rate  begins  to  be  significant  only  with  the  decade  from 
25  to  34.  Third,  the  rates  are  lower  for  colored  than 
for  white  persons ;  however,  this  applies  much  more  to 
males  than  to  females.  At  ages  25  to  34  the  rate  per 
hundred  thousand  for  white  males  is  8.2,  and  thereafter 
it  increases  very  rapidly,  reaching  its  maximum,  815.2, 
at  ages  75  and  over.  White  females  have  a  rate  of 
19.0  at  ages  25  to  34 — more  than  twice  as  much  as  the 
corresponding  figure  for  males.  As  the  curve  rises 
there  is  a  tendency  for  the  differences  between  the 
sexes  to  become  less,  so  that  in  the  last  age  class  the 

TABLE  1.— DEATH  RATES  FEOM  CANCER  (ALL  FORMS)  PER 

HUNDRED  THOUSAND  EXPOSED,  CLASSIFIED  BY  COLOR. 

SEX  AND  AGE  PERIOD* 


Age  Period 

All 
Persons 

White 
Males 

White 
Females 

Colored 
Males 

Colored 
Females 

69.7 

4.2 

1.5 

1.3 

2.7 

4.2 

15.9 

77.0 

198.8 

381.9 

603.1 

S17.5 

49.9 

4.1 

1.6 

1.5 

2.6 

4.6 

8.2 

38.1 

141.0 

361.4 

600.6 

815.2 

88.4 

4.4 

1.7 

1.2 

2.9 

3.9 

19.0 

100.8 

240.7 

420.6 

656.6 

862.0 

30.0 

2.9 

0.5 

0.5 

1.9 

1.5 

8.1 

27.9 

92.7 

174.6 

213.8 

308.0 

87.5 

1-  5 

2.9 

5-9 

0.5 

10-14 

0.9 

15-19 

3.1 

20-24 

5.3 

25-34 

33.6 

35-44 

121.8 

45-54 

247.9 

55-64 

354.6 

65-74 

431.0 

680.1 

*  Metropolitan     Life    Insurance    Company— Industrial    Department- 
mortahty  experience,  1911-1S14. 


rate  for  white  females  is  862.0 — only  a  slight  percent- 
age in  excess  of  the  corresponding  figure  for  males. 
Colored  males  uniformly  show  the  lowest  rates  of  the 
four  classes.  In  the  first  significant  age  class  they 
have  a  mortality  of  8.1.  With  advancing  years  the 
dift'erence  in  their  favor  becomes  greater,  so  that  in 
the  last  age  class  they  exhibit  a  rate  of  only  308.0 — 
less  than  half  that  of  the  next  higher  class.  Colored 
females  show  a  very  high  mortality  in  the  early  signifi- 
cant age  classes.  At  25  to  34  they  have  a  rate  of  33.6, 
almost  twice  that  of  white  females,  and  more  than 
four  times  that  of  white  males.  In  the  later  age 
classes,  however,  this  disadvantage  disappears,  so  that 


at  ages  75  and  over  they  have  a  mortahty  of  only  680.1, 
less  than  that  of  both  classes  of  whites. 

It  has  often  been  said  that  cancer  is  a  disease  of  the 
well-to-do.  If  our  figures  show  anything  it  is  that  the 
industrial  classes  enjoy  no  advantage.  The  rates  which 
I  have  just  quoted  indicate  this  point  clearly  on  com- 
parison with  those  for  the  Registration  Area,  which 
embraces  all  classes  of  the  population.  The  rates  for 
the  various  age  groups  of  the  white  male  industrial 
population  uniformly  exceed  by  10  per  cent,  or  more 
the  corresponding  figures  for  the  population  as  a 
whole;  the  rates  for  the  female  industrial  population 
fluctuate  about  the  corresponding  figures  for  the  Reg- 
istration Area,  being  sometimes  a.  little  above  and 
sometimes  a  little  below.  To  be  sure,  this  may  be  due 
to  the  greater  accuracy  of  the  insurance  data.  Be  that 
as  it  may,  we  can  distinctly  state  that  no  large  groups 
in  the  community  enjoy  any  special  immunity.  This  has 
been  confirmed  by  an  investigation  which  I  have 
recently  conducted  into  the  mortality  rates  of  the  prin- 
cipal races  of  our  population.  I  have  found  that  there 
is  little  to  justify  assertions  which  have  been  made  in 
the  literature  that  certain  of  the  races  enjoy  especial  or 
partial  immunity.  The  Jews,  for  example,  have  been 
singled  out  in  this  respect.  As  a  matter  of  fact,  the 
rate  for  Jews  is  sometimes  higher  than  for  the  native- 
born  Americans  of  the  corresponding  age  periods.  In 
1910,  for  example,  there  was  a  cancer  mortality  of 
150.0  per  hundred  thousand  at  ages  45  to  64,  among 
the  native  American  male  population  of  New  York 
State.  On  the  other  hand,  the  Russian-born  male 
population — an  overwhelming  majority  of  which  are 
Jews — had  a  rate  of  277.5  in  the  same  age  class. 

In  Table  2,  I  have  attempted  to  indicate  the  relative 
importance  of  the  several  forms  of  cancer  which  occur 
among  males  and  females  of  the  two  races.  It  will  be 
noted  that  among  white  males  about  half  of  the  can- 
cers affect  the  stomach  or  liver.  About  20  per  cent, 
more  relate  to  other  parts  of  the  digestive  system, 
namely,  the  buccal  cavity,  the  peritoneum,  the  intes- 
tines or  the  rectum.    Together  over  70  per  cent,  of  the 


cancers  among  males  are  so  accounted  for.  Among 
females,  cancer  of  the  genital  organs  and  cancer  of  the 
breast  are  very  prominent.  The  former  was  respon- 
sible for  43.1  per  cent,  of  all  the  cancer  deaths  occur- 
ring among  the  colored ;  15.9  per  cent,  in  addition  were 
due  to  breast  cancers.  Cancers  of  the  skin  are  much 
more  numerous  among  males  than  among  females ;  the 
rate  is  extremely  low  for  colored  persons,  being  vir- 
tually negligible  among  colored  females. 

In  general,  there  is  clearly  a  larger  proportion  of 
surgically  accessible  cases  among  females  than  among 
males.  Hospital  statistics  show  that  the  cancers  which 
are  responsible  for  a  large  part  of  the  female  mortality 

TABLE  2.— DEATHS  '  FBOM  CANCER  OF  SPECIFIED  ORGANS 

PER  HUNDRED  DEATHS  FROM  CANCER  OF  ALL 

FORMS,  CLASSIFIED  BT  COLOR  AND  SEX* 


Cancer  of  Specified 
Organs 


AU      I   White 
Persons  i   Males 


White  !  Colored 
Females;   Males 


Colored 
Females 


1.1  7.3    I        1.5 

33.9     '      53.5  21.5 


Cancer,  all  forms lOO.O  100.0 

Cancer  of  buccal  cavity j  3.7  9.6 

Cancer  of  stomach  and  liver 37. S  49.6 

Cancer  of  the  peritoneum,  in- 
testines and  rectum I  11.7  13.0          11.6    I      10.2            8.3 

Cancer    of   the  female  genital 

organs ,  21.1  ....           28.8           ....           43.1 

Cancer  of  the  breast 9.3  0.3          12.9            1.0    j      15.9 

Cancer  of  the  skin 2.6  4.5            1.9            3.2    ;        0.9 

Cancer  of  other  organs  or  of 

organs  not  specified '  13.9  23.0            9.8          24.9    :        8.8 

*  Metropolitan  Life  Insurance  Company— Industrial  Department- 
mortality  experience,  1911-1914. 

— those  of  the  genital  organs  and  of  the  breast — are 
most  susceptible  to  treatment.  At  Johns  Hopkins 
Hospital,  11.1  per  cent,  of  the  operations  for  cancers 
of  the  female  genital  organs  proved  fatal,  and  only 
5.5  per  cent,  of  the  cancers  of  the  breast.  We  may, 
therefore,  expect  a  large  reduction  in  the  female 
cancer  mortality  from  organized  efforts  to  bring 
cases  to  early  treatment. 

The  third  table  presents  the  average  ages  at  death 
of  the  persons  whp  have  died  of  cancer  of  the  various 
forms.  It  is  evident  that  the  average  age  of  females 
at  death  from  cancer  of  all  forms  is  about  two  and 
one-half  years  lower  than  that  of  males :  54.8  years 
as  against  57.2  years.   Among  males  the  average  age  at 


death  from  the  different  causes  varies  between  53.7 
(for  cancer  of  other  organs)  and  61.8  (for  cancer  of 
the  breast  and  cancer  of  the  skin).  Among  females 
the  variation  is  within  wider  Hmits,  the  minimum  age 
at  death  being  51.1  (for  cancer  of  the  female  genital 
organs)  and  the  maximum  being  63.7  (for  cancer  of 
the  skin).  The  age  at  death  for  cancer  of  the  buccal 
cavity,  cancer  of  the  breast  and  cancer  of  other  organs 
is  higher  among  males  than  among  females.  There 
are  slight  differences  in  favor  of  the  females,  on  the 
other  hand,  in  connection  with  cancer  of  the  stomach 
and  liver,  cancer  of  the  peritoneum,  intestines,  and 
rectum,  and  cancer  of  the  skin. 


TABLE  3.— AVERAGE  AGE  AT  DEATH  FROM  CANCER  OE 
SPECIFIED  ORGANS,  CLASSIFIED  BY  SEX* 


Cancer  of  Specified  Organs 


Average  Ages  of 


All 
Persons 


Males 


Females 


Cancer,  all  forms 

Cancer  of  the  buccal  cavity 

Cancer  of  the  stomach  and  liver 

Cancer  of  the  peritoneum,  intestines  and 

rectum 

Cancer  of  the  female  genital  organs 

Cancer  of  the  breast 

Cancer  of  the  skin 

Cancer  of  other  organs  or  of  organs  not 

specified 


55.5 
58.9 
58.3 

56.1 
51.1 
53.9 
62.7 

52.9 


57.2 
59.4 
58.3 

55.8 

ei.k 

61.8 
53.7 


54.8 
57.3 
58.4 

56.3 
51.1 

53.8 
63.7 

52.1 


*  Metropolitan  Life  Insurance  Company— Industrial  Department- 
mortality  experience,  1911-1914. 

A  consideration  of  the  average  ages  at  death  is 
important,  because  they  indicate  the  loss  to  the  com- 
munity that  is  occasioned  by  cancer  deaths.  At  55  the 
expectation  of  life  at  the  present  time  in  New  York 
City  is  over  fourteen  years;  at  60  it  is  almost  twelve 
years.  If,  for  the  sake  of  argument,  we  assume  an 
average  loss  to  the  community  of  fifteen  years  of  life 
for  each^cancer  death,  it  will  at  once  be  seen  how  huge 
is  the  loss  to  the  community  as  a  whole.  At  the  pres- 
ent time  a  conservative  estimate  places  the  total 
number  of  cancer  deaths  in  the  United  States  at  80,000 
a  year.  This  means  a  loss  to  the  community  of  an 
aggregate  of  1,200,000  years  of  life.  It  is  futile  to 
consider  the  monetary  value  of  this  loss ;  as  I  have 


already  pointed  out,  the  interest  of  the  community  in 
this  disease  is  not  primarily  economic.  Our  great 
desire  is  to  allay  the  suffering  of  the  many  thousands 
of  persons  who  annually  succumb,  and,  if  possible,  to 
extend  to  persons  of  middle  life  and  early  old  age  a 
few  additional  years  of  peaceful  enjoyment.  This  will 
be  a  gain  to  civilization  of  no  mean  value.  We  shall 
have  accomplished  much  if  we  assure  those  who  are 
just  entering  the  portals  of  old  age  that  the  declining 
years  of  their  life  will  not  be  beset  by  the  gaunt  spec- 
ter of  cancer.  That  the  happiness  of  thousands  of 
families  will  be  preserved,  and  that  thousands  of 
individuals  will  be  spared  unbearable  pain,  surely 
means  more  to  the  community  than  can  be  estimated  in 
terms  of  dollars  and  cents. 

To  accomplish  this  end,  two  lines  of  effort  are 
clearly  indicated.  The  first  is  immediate  and  unde- 
niable. It  is'  to  reduce,  by  the  best  means  at  our 
disposal,  the  suffering  and  premature  death  of  cancer 
patients.  At  the  present  time  the  greatest  promise  of 
success  is  held  out  by  the  surgeon.  The  average  dura- 
tion of  the  disease,  from  the  first  symptom  to  death, 
varies  considerably  with  the  form  and  location  of  the 
cancer;  but,  taken  together  for  all  forms  of  cancer, 
the  period  is  about  two  years.  The  records  of  surgical 
interference,  especially  those  of  the  Mayo  Clinic,  indi- 
cate a  marked  extension  of  life  of  the  patients  after 
operation.  While  no  absolute  figure  may  be  quoted, 
there  is  an  indication  that  an  expansion  of  life  of  about 
three  to  five  years  is  accomplished  for  about  half  of 
the  cases.  The  extent  of  the  additional  years  depends 
on  the  timeliness  of  the  operation,  the  failures  being 
the  advanced  cases.  If,  therefore,  it  can  be  arranged 
that  early  diagnosis  be  followed  by  immediate  opera- 
tion, the  average  duration  of  life  of  cancer  patients 
can  be  appreciably  prolonged.  If  an  average  of  five 
years  could  be  added  to  these  lives,  this  would  be 
equivalent  to  a  reduction  of  more  than  one  third  of 
the  total  loss.  This  is  clearly  the  community's  imme- 
diate program. 


The  second  line  of  effort  lies  in  investigating  into 
the  basic  facts  of  cancer — the  etiology  of  the  disease, 
its  method  of  dissemination,  the  problem  of  inheri- 
tance, and,  finally,  the  measures  of  relief.  This  is  the 
field  of  the  pathologist  and  the  surgeon,  rather  than 
of  the  statistician,  the  sociologist,  or  the  lay  investi- 
gator. I  wish  to  devote  brief  attention,  however,  to  a 
contribution  to  this  effort  which  is  being  made  by  the 
life  insurance  companies,  and  which  promises  to  cast 
valuable  light  on  the  entire  problem. 

At  the  request  of  the  American  Society  for  the 
Control  of  Cancer,  a  committee^  representing  the 
largest  life  insurance  companies  has  made  all  the 
necessary  preparations  to  carry  on  a  special  study  of 
the  life  insurance  returns  for  two  forms  of  cancer 
which  are  readily  diagnosed,  namely,  cancer  of  the 
buccal  cavity  and  cancer  of  the  breast.  Special  forms 
have  been  drawn  up  for  this  purpose,  covering  the 
following  points : 

INQUIRY  BLANK  FOR  THE  STUDY  OF  CANCER  OF  THE 
BREAST  (OR  OF  THE  BUCCAL  CAVITY) 

Name  of  patient;   address;  department;   claim  number. 

Personal  and  social  facts  about  deceased:  color;  sex;  nearest  age  at 
death;  place  of  birth;  birthplace  of  deceased's  mother  (if  readily  ascer- 
tainable).    Was  deceased  single,  married,  widowed  or  divorced? 

Occupation:  general  nature  of  industry  or  business;  trade  or  par- 
ticular kind  of  work. 

Family  history  of  deceased:  Have  other  members  of  deceased's 
immediate  family  died  from  cancer  of  the  breast  (or  buccal  cancer)  ? 
Have  other  members  of  deceased's  immediate  family  died  from  other 
forms  of  cancer?  Have  other  members  of  deceased's  immediate  family 
had  and  survived  any  form  of  cancer?  If  so,  state  relationship;  also 
give  type  of  cancer. 

History  of  breast  lesions:  Any  history  of  blow,  wound,  irritation  or 
other  injury  to  breast?  Please  specify.  Type  of  mammary  gland 
(large,  small,  adipose?).  Lactation:  first  and  last  date  of  lactation  if 
possible.  Any  difficulty  with  lactation?  Any  history  of  mastitis? 
Habits:    Was  deceased  a  vegetarian?     A  heavy  meat   eater? 

History  of  buccal  lesions:  Any  history  of  irritation  from  teeth?  Any 
history  of  other  irritation  or  injury  to  buccal  cavity?  Any  history  of 
syphilis?  Leukoplakia?  Habits:  Did  deceased  use  alcoholic  beverages? 
Abstainer?  Moderate  user?  Excessive  user?  Did  deceased  use  tobacco? 
Pipe?  Cigar?  Cigaret?  Chew?  Was  deceased  a  vegetarian?  A  heavy 
meat  eater? 

1.  Mr.  Arthur  Hunter,  New  York  Life,  chairman;  Dr.  F.  C.  Wells, 
Equitable  Life;  Dr.  W.  A.  Jaquith,  Prudential;  Dr.  Brandreth  Symonds, 
Mutual   Life,  and   Louis  I.   Dublin,  Metropolitan   Life. 


Cancer  history:  Date  when  first  symptoms  were  observed.  Type  ol 
tumor  when  first  observed.     Location  of  initial  tumor.     Metastasis  to  — . 

Type  of  tumor  at  time  of  death.     Location  of  tumor  at  time  of  death. 

Cancer  treatment:  Give  approximate  dates,  kind  of  treatment  and 
results:  (a)  medical  treatment;  (b)  surgical  treatment;  (c)  other  treat- 
ment   (Roentgen-ray,   radium   or   other). 

Other   diseases  or   conditions   intercurrent   with   cancer. 

Pathologic  report:  Gross  appearance  of  tumor  (if  of  the  breast,  was 
the  skin  or  muscle,  or  both  involved?).  Microscopic  report  (if  of  the 
breast,  give  details   of  structure   of  growth). 

Necropsy  report:     Please  give  findings. 

Any   other   information   of  value. 

Date,  and   signature  of  physician. 

The  plan  is  to  send  one  of  these  blanks  to  each  of 
the  physicians  who  sign  the  death  certificates  on  the 
claim  papers  returned  to  the  life  insurance  companies, 
and  to  ask  for  more  information  with  reference  to  the 
case.  By  these  means  the  companies  hope  to  obtain 
all  the  important  facts  with  reference  to  the  history  of 
the  deceased  and  of  his  or  her  family.  The  history  of 
the  lesion  is  gone  into  fully,  to  determine  whether 
there  has  been  any  blow,  wound  or  irritation ;  the  can- 
cer history  is  listed,  as  well  as  the  nature  of  the  treat- 
ment. Record  of  necropsy  or  of  pathologist's  report  is 
called  for.  We  hope  to  receive  this  information  in  a 
large  proportion  of  cases,  and  at  the  end  of  a  requisite 
period  the  entire  material  will  be  analyzed  as  a  unit 
and  a  report  will  be  issued.  Thus  we  trust  that  we 
shall  be  able  to  add  materially  to  the  amount  of  exact 
knowledge  with  reference  to  cancer. 

The  insurance  companies,  as  well  as  the  American 
Society  for  the  Control  of  Cancer,  hope  and  trust  that 
these  forms  will  receive  the  careful  attention  of 
specialists  and  general  practitioners,  and  the  enthusi- 
astic cooperation  of  the  medical  profession  is  confi- 
dently counted  on  as  one  of  the  essential  instruments 
in  this  investigation. 


10 


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^erest^^ofjhecommm^    in  cancer 


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